The role of surgeon-performed ultrasound in patients with possible cardiac wounds

Diagnostic performance of sonography in penetrating torso trauma: a systematic review and meta-analysis

BACKGROUND

This systematic review investigates the diagnostic value of ultrasound in the evaluation of torso injuries following a penetrating trauma.

METHODS

We searched PubMed, Scopus, and WOS databases for related original articles until May 7, 2023, and extracted data related to diagnostic performance. The bivariate model and hierarchic summary receiver operating characteristic (HSROC) approach were used to calculate pooled diagnostic values. Cochrane Q test and I-squared were performed to evaluate heterogeneity. We assessed heterogeneity with meta-regression.

RESULTS

Seventeen studies were included, which involved a total number of 1866 patients. According to meta-analysis, sonography demonstrated a pooled sensitivity of 56% (45-67%) and specificity of 96% (94-97%), positive likelihood ratio (LR +) of 13.66 (8.03-23.23), and negative likelihood ratio (LR-) of 0.45 (0.35-0.59) for detecting abdominal injuries. In pericardial penetrating trauma, pooled sensitivity was 100% (45-100%), pooled specificity was 99% (96-100%), LR + was 136.7 (24.8-752.3), and LR- was 0.00 (0.00-1.22). For thoracic penetrating trauma, pooled sensitivity was 99% (93-100%) and specificity was 100% (98-100%).

CONCLUSIONS

Sonography demonstrated promising diagnostic value in the initial assessment of torso penetrating trauma, particularly in the thoracic and pericardial regions. However, the sensitivity of sonography is limited in abdominal penetrating trauma and a combination with other imaging modalities should be considered in these cases.

A meta-analysis of the diagnostic accuracy of chest ultrasound for the diagnosis of occult penetrating cardiac injuries in hemodynamically stable patients with penetrating thoracic trauma

BACKGROUND

We performed a systematic review (SR) and meta-analysis (MA) to determine the diagnostic accuracy of chest ultrasound (US) compared with a pericardial window (PW) for the diagnosis of occult penetrating cardiac injuries in hemodynamically stable patients with penetrating thoracic trauma.

METHODS

A literature search in five databases identified relevant articles for inclusion in this SR and MA. Studies were eligible if they evaluated the diagnostic accuracy of chest US, compared with a PW, for the diagnosis of occult penetrating cardiac injuries in hemodynamically stable patients presenting with penetrating thoracic trauma. Two investigators independently assessed articles for inclusion and exclusion criteria and selected studies for final analysis. Methodological quality was evaluated using Quality Assessment of Diagnostic Accuracy Studies-2. We performed a MA of binary diagnostic test accuracy within the bivariate mixed-effects logistic regression modeling framework.

RESULTS

We included five studies in our SR and MA. These studies included a total of 556 trauma patients. The MA found that, compared with PW, the US was 79% sensitive and 92% specific for detecting occult penetrating cardiac injuries in hemodynamically stable patients. The presence of a concomitant left hemothorax was frequent in patients with false-negative results.

CONCLUSION

This SR and MA found that, compared with PW, US was 79% sensitive and 92% specific for detecting occult penetrating cardiac injuries in hemodynamically stable patients with penetrating thoracic trauma. Caution interpretation of pericardial US results is suggested in the presence of left hemothorax. In these cases, a second diagnostic test should be performed.

LEVEL OF EVIDENCE

Systematic Review and Meta-analysis, level II.

The Role of Ultrasound for Detecting Occult Penetrating Cardiac Wounds in Hemodynamically Stable Patients

BACKGROUND

There is evidence in favor of using the ultrasound as the primary screening tool in looking for an occult cardiac injury. We report on a prospective single-center study to determine the diagnostic accuracy of chest ultrasound for the diagnosis of occult penetrating cardiac wounds in a low-resource hospital from a middle-income country.

METHODS

Data were collected prospectively. We included all consecutive patients 14 years and older who presented to the Emergency Trauma Unit with (1) penetrating injuries to the precordial area and (2) a systolic blood pressure ≥ 90 mmHg (hemodynamically stable). The main outcome measures were sensitivity, specificity, and positive and negative predictive values of ultrasound compared with those of the pericardial window, which was the standard test.

RESULTS

A total of 141 patients met the inclusion criteria. Our results showed that for diagnosing an occult cardiac injury, the sensitivity of the chest ultrasonography was 79.31%, and the specificity was 92.86%. Of the 110 patients with a normal or negative ultrasound, six had a positive pericardial window. All of these patients had left hemothoraces. None of them required further cardiac surgical interventions.

CONCLUSION

We found that ultrasound was 79% sensitive and 92% specific for the diagnosis of occult penetrating cardiac wounds. However, it should be used with caution in patients with injuries to the cardiac zone and simultaneous left hemothorax.

The top 100 manuscripts in emergency cardiac surgery. Potential role in cardiothoracic training. A bibliometric analysis

Background

Emergency Cardiac Surgery (ECS) is a component of cardiothoracic training. Citations are considered to represent a papers influence. Bibliometric analyses allow us to identify the most influential work, and future research. We aim to highlight the key research themes within ECS and determine their potential impact on cardiothoracic training.

Methods

Thomas Reuters Web of Science was searched using terms [Emergency AND Card* AND Surg*]. Results were ranked by citation and reviewed by a panel of cardiac surgeons to identify the top 100 cited papers relevant to ECS. Papers were analysed by topic, journal and impact. Regression analysis was used to determine a link between impact factor and scientific impact.

Results

3823 papers were identified. Median citations for the top 100 was 88. The paper with the highest impact was by Nashef et al. focusing on the use of EuroSCORE (2043 citations). The Annals of Thoracic Surgery published most papers (n = 18:1778 citations). The European Journal of Cardiothoracic Surgery coveted the most citations (n = 2649). The USA published most papers (n = 55).The most ubiquitous topics were; risk stratification, circulatory support and aortic surgery. A positive relationship between journal impact fact and the scientific impact of manuscripts in ECS (P = 0.043) was deduced.

Conclusion

This study is the first of its kind and identified the papers which are likely to the contribute most to training and understanding of ECS. A papers influence is partially determined by journal impact factor. Bibliometric analysis is a potent tool to identify surgical training needs.

Focused assessment with sonography in trauma (FAST) for the regional anesthesiologist and pain specialist

This article in our point-of-care ultrasound (PoCUS) series is dedicated to the role the focused assessment with sonography in trauma (FAST) exam plays for the regional anesthesiologist and pain specialists in the perioperative setting. The FAST exam is a well-established and extensively studied PoCUS exam in both surgical and emergency medicine literature with over 20 years demonstrating its benefit in identifying the presence of free fluid in the abdomen following trauma. However, only recently has the FAST exam been shown to be beneficial to the anesthesiologist in the perioperative setting as a means to identify the extravasation of free fluid into the abdomen from the hip joint following hip arthroscopy. In this article, we will describe how to obtain the basic FAST views (subcostal four-chamber view, perihepatic right upper quadrant view, perisplenic left upper quadrant view, and pelvic view in the longitudinal and short axis) as well as cover the relevant sonoanatomy. We will describe pathological findings seen with the FAST exam, primarily free fluid in the peritoneal space as well as in the pericardial sac. As is the case with any PoCUS skill, the application evolves with understanding and utilization by new clinical specialties. Although this article will provide clinical examples of where the FAST exam is beneficial to the regional anesthesiologist and pain specialist, it also serves as an introduction to this powerful PoCUS skill in order to encourage clinical practitioners to expand the application of the FAST exam within the scope of regional anesthesia and pain management practice.

Non-operative management is feasible for selected blunt trauma patients with pericardial effusion

BACKGROUND

Blunt pericardial effusion (BPE) in trauma patients can be suggestive of injuries to the heart or great vessels. Surgical exploration is the mainstay of management; however, the effectiveness of non-operative management in this patient group remains unclear.

METHODS

Patients presenting with BPE in the trauma registry system at our level I trauma center were reviewed. Patients with and without cardiovascular (CVS) injury were compared to identify predictors for CVS injury and to understand the factors related to the requirement for surgery. Patients with and without CVS injury who presented with stable hemodynamics and initially received conservative management were also compared.

RESULTS

Thirty patients were enrolled in the study with a mean age of 53.2 (standard deviation (SD) 18.0) years and a mean injury severity score (ISS) of 26.7 (SD 9.0). Eleven patients presented with systolic blood pressure (SBP)<100mmHg, and immediate surgical intervention was performed. Eight patients had evidence of CVS injury (73%). Nineteen patients had stable hemodynamics and initially received conservative treatment. Of these, twelve patients received further surgical interventions, and only three had evidence of CVS injury (16%, 3/19). Comparisons of individuals with and without CVS injury revealed that the SBP on presentation was higher in patients without CVS injury than in those with CVS injury (132.7 (SD 41.3) mmHg vs. 95.6 (SD 21.1) mmHg). Clinically irrelevant differences between the two groups were observed for the creatine kinase (CK)-MB level, the troponin I level, the presence of an echocardiography tamponade sign, associated chest trauma and ISS. No remarkable predictors for CVS injury were found in hemodynamically stable patients.

CONCLUSION

Non-operative management can be considered for patents with traumatic BPE and stable hemodynamics; however, this approach must be performed at an institution with adequate facilities and well-trained staff.

Abdominal Trauma Revisited

Although abdominal trauma has been described since antiquity, formal laparotomies for trauma were not performed until the 1800s. Even with the introduction of general anesthesia in the United States during the years 1842 to 1846, laparotomies for abdominal trauma were not performed during the Civil War. The first laparotomy for an abdominal gunshot wound in the United States was finally performed in New York City in 1884. An aggressive operative approach to all forms of abdominal trauma till the establishment of formal trauma centers (where data were analyzed) resulted in extraordinarily high rates of nontherapeutic laparotomies from the 1880s to the 1960s. More selective operative approaches to patients with abdominal stab wounds (1960s), blunt trauma (1970s), and gunshot wounds (1990s) were then developed. Current adjuncts to the diagnosis of abdominal trauma when serial physical examinations are unreliable include the following: 1) diagnostic peritoneal tap/lavage, 2) surgeon-performed ultrasound examination; 3) contrast-enhanced CT of the abdomen and pelvis; and 4) diagnostic laparoscopy. Operative techniques for injuries to the liver, spleen, duodenum, and pancreas have been refined considerably since World War II. These need to be emphasized repeatedly in an era when fewer patients undergo laparotomy for abdominal trauma. Finally, abdominal trauma damage control is a valuable operative approach in patients with physiologic exhaustion and multiple injuries.

Blunt and Penetrating Cardiac Trauma

Patients with traumatic cardiac injuries can present with wide variability in their severity of illness. The most severe will present in cardiac arrest, whereas the most benign may be altogether asymptomatic; most will fall somewhere in between. Management of cardiac injuries largely depends on mechanism of injury and patient physiology. Understanding the spectrum of injuries and their associated manifestations can help providers react more quickly and initiate potentially life-saving therapies more efficiently when time is critical. This article discusses the workup and management of both blunt and penetrating cardiac injuries.

Penetrating cardiac injuries: A 36-year perspective at an urban, Level I trauma center

BACKGROUND

This study evaluates patterns of injuries and outcomes from penetrating cardiac injuries (PCIs) at Grady Memorial Hospital, an urban, Level I trauma center in Atlanta, Georgia, over 36 years.

METHODS

Patients sustaining PCIs were identified from the Trauma Registry of the American College of Surgeons and the Emory Department of Surgery database; data of patients who died prior to any therapy were excluded. Demographics and outcomes were compared over three time intervals: Period 1 (1975-1985; n = 113), Period 2 (1986-1996; n = 79), and Period 3 (2000-2010; n = 79).

RESULTS

Two hundred seventy-one patients (86% were male; mean age, 33 years; initial base deficit = -11.3 mEq/L) sustained cardiac stab (SW, 60%) or gunshot wounds (GSW, 40%). Emergency department thoracotomy was performed in 67 (25%) of 271 patients. Overall mortality increased in the modern era (Period 1, 27%, vs. Period 2, 22%, vs. Period 3, 42%; p = 0.03) along with GSW mechanisms (Period 1, 32%, vs. Period 2, 33%, vs. Period 3, 57%; p = 0.001), GSW mortality (Period 1, 36%, vs. Period 2, 42%, vs. Period 3, 56%; p = 0.04), and multichamber injuries (Period 1, 12%, vs. Period 2, 10%, vs. Period 3, 34%; p< 0.001). In Period 3, GSWs (n = 45) resulted in multichamber injuries in 28 patients (62%) and multicavity injuries in 19 patients (42%). Surgeon-performed ultrasound accurately identified pericardial blood in 55 of 55 patients in Period 3.

CONCLUSIONS

Increased frequency of GSWs in the past decade is associated with increased overall mortality, multichamber injuries, and multicavity injuries. Ultrasound is sensitive for detection of PCI.

LEVEL OF EVIDENCE

Therapeutic study, level IV; epidemioligc study, level III.

Management of chest trauma

Trauma is the leading cause of death worldwide. Approximately 2/3 of the patients have a chest trauma with varying severity from a simple rib fracture to penetrating injury of the heart or tracheobronchial disruption. Blunt chest trauma is most common with 90% incidence, of which less than 10% require surgical intervention of any kind. Mortality is second highest after head injury, which underlines the importance of initial management. Many of these deaths can be prevented by prompt diagnosis and treatment. What is the role of the thoracic surgeon in the management of chest trauma in severely injured patients? When should the thoracic surgeon be involved? Is there a place for minimal invasive surgery in the management of severely injured patients? With two case reports we would like to demonstrate how the very specific knowledge of thoracic surgeons could help in the care of trauma patients.

Getting a better look: Outcomes of laparoscopic versus transdiaphragmatic pericardial window for penetrating thoracoabdominal trauma at a Level I trauma center

BACKGROUND

In penetrating thoracoabdominal trauma, it is necessary to evaluate both the pericardial fluid and the diaphragm directly. Transdiaphragmatic pericardial windows (TDWs) provide direct access to the pericardium and diaphragm but expose the patient to the risks of laparotomy. We hypothesize that transabdominal laparoscopic pericardial windows (LPWs) are a safe and effective alternative to TDWs in stable patients.

METHODS

This is a retrospective observational study of stable patients with thoracoabdominal penetrating trauma at a level I trauma center between January 2007 and June 2015, comparing outcomes after TDW versus LPW.

RESULTS

A total of 99 patients with penetrating trauma had a diagnostic pericardial window, 33 of which were laparoscopic. Stab wounds were most common (80, 80.8%) compared with gunshot wounds (19, 19.2%). Of 11 patients who had a positive pericardial window, 10 (90.9%) were associated with a cardiac injury. There was no difference in the ratio of positive pericardial windows for patients who had TDW versus LPW (8/66, 12.1% vs. 3/33, 9.1%; p = 0.651). One patient had a complication related to a negative pericardial window in the laparoscopic group. There was no difference in complication rates between TDW and LPW (p = 0.155). Mean length of stay was longer in TDW compared with LPW (12 vs. 5 days, p = 0.046). One patient died during index admission in the TDW group, but there was no difference in mortality rates between TDW and LPW during the index admission (p = 0.477). Median length of follow-up was 29 days (range, 0-2,709). On long-term follow-up, there was also no difference in mortality rates between TDW and LPW (2/66, 3.0% vs. 2/33, 6.1%; p = 0.470).

CONCLUSION

In hemodynamically stable patients with thoracoabdominal injuries, LPW is a safe and effective technique in evaluating both pericardial fluid and the diaphragm. LPW is a viable alternative to exploratory laparotomy and TDWs.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

The early hospital management of gunshot wounds. Part 1: head, neck and thorax

The management of gunshot wounds is an increasing problem for UK emergency doctors, but not to an extent where it has become routine or allowed individuals to gain significant experience in their treatment. This article reviews the pathophysiology of gunshot injury in general before examining the evidence available concerning the management of gunshot wounds to the head neck and thorax.

Cost-effectiveness of the Cardiac Component of the Focused Assessment of Sonography in Trauma Examination in Blunt Trauma

BACKGROUND

Blunt cardiac injury severe enough to require surgical intervention (sBCI) is an exceedingly rare event occurring in approximately 1 out of every 1600 trauma patients. While performing the cardiac component of the Focused Assessment of Sonography in Trauma (cFAST) exam is effective in penetrating trauma, it is unclear whether it is of value in blunt trauma given the low prevalence of sBCI, the imperfect test characteristics of the FAST exam, and the rate of incidental pericardial effusion.

OBJECTIVE

The objective was to determine through decision analysis whether performing the cFAST exam is cost-effective in the evaluation of hypotensive and normotensive blunt trauma patients.

METHODS

We created two decision analytic models using commercially available software (TreeAgePro2011) to evaluate the cost-effectiveness of the cFAST in hypotensive (systolic blood pressure <90 mm Hg) and normotensive blunt trauma patients. Clinical probabilities were obtained from published data. Costs were estimated from Medicare reimbursement and charge data. The willingness-to-pay threshold was $50,000/quality-adjusted life-years (QALYs). Sensitivity analyses were performed over plausible ranges using available literature.

RESULTS

In hypotensive patients, for the base case scenario of a 34-year-old with blunt trauma, the cFAST strategy had a cost of $42,882.70 and an effectiveness of 25.3597 QALYs, whereas the no cFAST strategy had a cost of $42,753.52 and an effectiveness of 25.3532 QALYs. The incremental cost-effectiveness ratio (ICER) was $19,918/QALY. For normotensive patients the cFAST strategy had a cost of $18,331.03 and an effectiveness of 23.2817 QALYs, whereas the no cFAST strategy had a cost of $18,207.58 and an effectiveness of 23.2814 QALYs. The ICER was $465,867/QALY. In the sensitivity analyses, age, probability of death from sBCI with prompt treatment, and probability of sBCI were the main drivers of variability in the model outcomes.

CONCLUSIONS

The cFAST for blunt trauma is cost-effective for hypotensive but not for normotensive patients. The ICER for hypotensive patients was more than 20 times higher than the ICER for normotensive patients. Our results suggest that performing the cFAST exam may not be an effective use of resources in normotensive blunt trauma patients.

Cardiac Injuries: A Review of Multidetector Computed Tomography Findings

Trauma is the leading cause of death in United States in the younger population. Cardiac trauma is common following blunt chest injuries and is associated with high morbidity and mortality. This study discusses various multidetector computed tomography (MDCT) findings of cardiac trauma. Cardiac injuries are broadly categorized into the most commonly occurring blunt cardiac injury and the less commonly occurring penetrating injury. Signs and symptoms of cardiac injury can be masked by the associated injuries. Each imaging modality including chest radiographs, echocardiography, magnetic resonance imaging and MDCT has role in evaluating these patients. However, MDCT is noninvasive; universally available and has a high spatial, contrast, and temporal resolution. It is a one stop shop to diagnose and evaluate complications of cardiac injury. MDCT is an imaging modality of choice to evaluate patients with cardiac injuries especially the injuries capable of causing hemodynamic instability.

Trauma sternotomy for presumed haemopericardium with incidental coccidioidal pericarditis

Background

Disseminated cocciodiomycosis with extrapulmonary disease occurs in less than 1% of infected patients, with few cases involving the pericardium reported in the literature. A subxiphoid window in a focussed assessment with sonography for trauma is a fast and reliable study for detecting haemopericardium in the haemodynamically unstable injured patient.

Methods

Case report and literature review.

Case report

A 50-year old man presented in extremis following a stab wound to the right thoracoabdominal region with a positive pericardial ultrasound. At the time of emergent sternotomy, the pericardial effusion appeared non-traumatic and not the cause of haemodynamic instability. Lung, diaphragm, liver and transverse colon lacerations were controlled by laparotomy. He was discovered to have extensive adenopathy within the mediastinum, porta hepatis, and lesser sac, which after histopathologic examination, demonstrated granulomatous lymphadenitis consistent with disseminated cocciodiomycosis.

Conclusions

This case report describes the first reported “incidental” pericardial effusion in a haemodynamically unstable patient sustaining a thoracoabdominal stab wound discovered on a positive ultrasound study. Emergent operative exploration and subsequent workup determined the pericardial fluid to be of infectious origin, rather than traumatic. With the incidence of cocciodiomycosis within endemic geographic regions significantly rising, coccidioidal pericarditis may become an increasingly relevant cause of fluid detected on noninvasive pericardial examination.

Screening for occult penetrating cardiac injuries

OBJECTIVE

To determine the sensitivity of emergency department ultrasonography (US) in the diagnosis of occult cardiac injuries.

BACKGROUND

Internationally, US has become the investigation of choice in screening patients for a possible cardiac injury after penetrating chest trauma by detecting blood in the pericardial sac.

METHODS

Patients presenting with a penetrating chest wound and a possible cardiac injury to the Groote Schuur Hospital Trauma Centre between October 2001 and February 2009 were prospectively evaluated. All patients were hemodynamically stable, had no indication for emergency surgery, and had an US scan followed by subxiphoid pericardial window exploration.

RESULTS

There were a total of 172 patients (median age = 26 years; range, 11-65 years). The mechanism of injury was stab wounds in 166 (96%) and gunshot wounds in 6. The sensitivity of US in detecting hemopericardium was 86.7%, with a positive predictive value of 77%. There were 18 false-negatives. Eleven of these false-negatives had an associated hemothorax and 6 had pneumopericardium. A single patient had 2 negative US examinations and returned with delayed cardiac tamponade.

CONCLUSIONS

The sensitivity of US to detect hemopericardium in stable patients was only 86.7%. The 2 main factors that limit the screening are the presence of a hemothorax and air in the pericardial sac. A new regimen for screening of occult injuries to make allowance for this is proposed.

International evidence-based recommendations for focused cardiac ultrasound

BACKGROUND

Focused cardiac ultrasound (FoCUS) is a simplified, clinician-performed application of echocardiography that is rapidly expanding in use, especially in emergency and critical care medicine. Performed by appropriately trained clinicians, typically not cardiologists, FoCUS ascertains the essential information needed in critical scenarios for time-sensitive clinical decision making. A need exists for quality evidence-based review and clinical recommendations on its use.

METHODS

The World Interactive Network Focused on Critical UltraSound conducted an international, multispecialty, evidence-based, methodologically rigorous consensus process on FoCUS. Thirty-three experts from 16 countries were involved. A systematic multiple-database, double-track literature search (January 1980 to September 2013) was performed. The Grading of Recommendation, Assessment, Development and Evaluation method was used to determine the quality of available evidence and subsequent development of the recommendations. Evidence-based panel judgment and consensus was collected and analyzed by means of the RAND appropriateness method.

RESULTS

During four conferences (in New Delhi, Milan, Boston, and Barcelona), 108 statements were elaborated and discussed. Face-to-face debates were held in two rounds using the modified Delphi technique. Disagreement occurred for 10 statements. Weak or conditional recommendations were made for two statements and strong or very strong recommendations for 96. These recommendations delineate the nature, applications, technique, potential benefits, clinical integration, education, and certification principles for FoCUS, both for adults and pediatric patients.

CONCLUSIONS

This document presents the results of the first International Conference on FoCUS. For the first time, evidence-based clinical recommendations comprehensively address this branch of point-of-care ultrasound, providing a framework for FoCUS to standardize its application in different clinical settings around the world.

Otolaryngologist-performed head and neck ultrasound: outcomes and challenges in learning the technique

Objective:

To assess the feasibility and accuracy of otolaryngologist-performed ultrasound in evaluating head and neck pathology.

Method:

An ENT trainee, who had undergone basic training in neck ultrasonography, performed this on patients referred with suspected neck pathology. The trainee recorded the presence and nature of any abnormality. Findings were compared with those from a repeated scan performed by an experienced head and neck radiologist.

Results:

The study included 250 patients. The absence or presence of lesion as reported by the trainee correlated with the radiologist's findings in 207 cases (83 per cent). There were 144 true positives, 63 true negatives, 32 false negatives and 11 false positives, yielding a sensitivity of 82 per cent, specificity of 85 per cent and accuracy of 83 per cent. Of the 144 true positive lesions, 81 per cent were interpreted concordantly with the radiologist.

Conclusion:

Neck ultrasonography performed by an otolaryngologist is less accurate than that performed by an experienced radiologist, but is still a useful adjunct to clinical assessment, facilitating assessment in a ‘one-stop’ clinical setting.

Sternotomy or drainage for a hemopericardium after penetrating trauma: a randomized controlled trial

OBJECTIVE

To determine if stable patients with a hemopericardium detected after penetrating chest trauma can be safely managed with pericardial drainage alone.

BACKGROUND

The current international practice is to perform a sternotomy and cardiac repair if a hemopericardium is detected after penetrating chest trauma. The experience in Cape Town, South Africa, on performing a mandatory sternotomy in hemodynamically stable patients was that a sternotomy was unnecessary and the cardiac injury, if present, had sealed.

METHODS

A single-center parallel-group randomized controlled study was completed. All hemodynamically stable patients with a hemopericardium confirmed at subxiphoid pericardial window (SPW), and no active bleeding, were randomized. The primary outcome measure was survival to discharge from hospital. Secondary outcomes were complications and postoperative hospital stay.

RESULTS

Fifty-five patients were randomized to sternotomy and 56 to pericardial drainage and wash-out only. Fifty-one of the 55 patients (93%) randomized to sternotomy had either no cardiac injury or a tangential injury. There were only 4 patients with penetrating wounds to the endocardium and all had sealed. There was 1 death postoperatively among the 111 patients (0.9%) and this was in the sternotomy group. The mean intensive care unit (ICU) stay for a sternotomy was 2.04 days (range, 0-25 days) compared with 0.25 days (range, 0-2) for the drainage (P < 0.001). The estimated mean difference highlighted a stay of 1.8 days shorter in the ICU for the drainage group (95% CI: 0.8-2.7). Total hospital stay was significantly shorter in the SPW group (P < 0.001; 95% CI: 1.4-3.3).

CONCLUSIONS

SPW and drainage is effective and safe in the stable patient with a hemopericardium after penetrating chest trauma, with no increase in mortality and a shorter ICU and hospital stay. (ClinicalTrials.gov Identifier: NCT00823160).

Cardiac trauma during teenage years

The spectrum of blunt cardiac trauma ranges from asymptomatic myocardial contusion to fatal cardiac arrhythmias and/or cardiac rupture. Although cardiac rupture is common in fatal traffic accidents, these patients rarely reach hospital care. Insignificant blunt cardiac injury during sports may cause fatal arrhythmia in teens. Penetrating cardiac trauma is fairly common in the United States, encountered frequently in major urban centers. Most cases are dead at the scene and never reach hospital. The incidence of cardiac sequelae in survivors is high, and these patients should be evaluated with early and late echocardiography to detect anatomic or functional cardiac involvement.

The J-wave: a new electrocardiographic sign of an occult cardiac injury

BACKGROUND

The aim of this study was to determine the sensitivity and specificity of a J wave on the electrocardiogram (ECG) to detect an occult cardiac injury in patients following penetrating chest trauma.

METHOD

A prospective study conducted on patients admitted to the Groote Schuur Hospital Trauma Centre following penetrating chest trauma during the period of 1st October 2001 and 28th February 2009, who did not have an indication for emergency surgery and that underwent an ECG and later a subxiphoid pericardial window (SPW) for a potential cardiac injury. All the patients were easily resuscitatable with less than 2l of crystalloid. A standard 12-lead ECG was performed shortly after admission. A J wave was defined as the small positive reflection on the R-ST junction.

RESULTS

There were 174 patients where an ECG was performed and the patient underwent SPW for a possible cardiac injury. The mean age of the patients was 28 years (range 11-65). The mechanism of injury was stab wounds in 167 patients and 7 low velocity gunshot wounds. A J-wave was present on the ECG in 65 (37%) of the 174 patients with a possible cardiac injury. The sensitivity of a J wave to detect a hemopericardium was 44%, specificity was 85%, and positive predictive value of 91% (p<0.001).

CONCLUSION

The presence of a 'J' wave on ECG signifies a significant risk of an occult cardiac injury after penetrating thoracic trauma.

Point of care cardiac ultrasound applications in the emergency department and intensive care unit--a review

The use of point of care echocardiography by non-cardiologist in acute care settings such as the emergency department (ED) or the intensive care unit (ICU) is very common. Unlike diagnostic echocardiography, the scope of such point of care exams is often restricted to address the clinical questions raised by the patient's differential diagnosis or chief complaint in order to inform immediate management decisions. In this article, an overview of the most common applications of this focused echocardiography in the ED and ICU is provided. This includes but is not limited to the evaluation of patients experiencing hypotension, cardiac arrest, cardiac trauma, chest pain and patients after cardiac surgery.

Penetrating cardiac injury and the significance of chest computed tomography findings

In rare circumstances, hemodynamically stable patients can harbor serious penetrating cardiac injuries. We hypothesized that chest computed tomography (CCT) is potentially useful in evaluation. The records of all patients admitted to our center with wounds to the precordium or who sustained a hemothorax or pneumothorax after penetrating torso injuries over a 48-month period were reviewed. Those having an admission CCT were studied. The potential diagnostic value of hemopericardium (HPC) and pneumopericardium (PPC) on CCT was examined. Most of the 333 patients were male [293 (88.0 %)] with a roughly equal distribution of gunshot [189 (56.8 %)] and stab [144 (43.2 %)] wounds. Mean age was 28.7 ± 12.6 years. Thirteen (3.9 %) patients had cardiac injuries that were operatively managed. Eleven (3.3 %) CCT studies demonstrated HPC and/or PPC. Ten of these patients had an injury with one false positive. Retained hemothorax and proximity findings on the three false negative CCT studies led to video-assisted thoracoscopic surgery or subxiphoid exploration with diagnosis of the injury. HPC and/or PPC on CCT had a sensitivity of 76.9 %, specificity of 99.7 %, positive predictive value of 90.9 %, and negative predictive value (NPV) of 99.1 % for cardiac injuries. However, including all findings that changed management, CCT had a sensitivity and NPV of 100 %. CCT is a potentially useful modality for the evaluation of cardiac injuries in high-risk stable patients. The presence of HPC and/or PPC on CCT after penetrating thoracic trauma is highly indicative of a significant cardiac injury.

Retrospective study of heart injuries occurred in Manaus - Amazon

OBJECTIVE

To evaluate the forms of treatment employed to heart injuries and the main aspects related to their morbidity and mortality.

METHODS

A retrospective study of 102 patients with cardiac injuries treated in the two emergency rooms in Manaus (Dr. John Lucio Pereira Machado Emergency Hospital and August 28 County Emergency Hospital) from January 1998 to June 2006.

RESULTS

Of the 102 patients, 95.1% were men; mean age was 27 years; stab wounds accounted for 81.4% of cases and gunshot wounds for 18.6%; cardiorrhaphy was performed in 98.1% of cases. The heart chambers affected were: Right Ventricle (RV): 43.9% (36.2% isolated and 7.7% associated with other chambers); Left Ventricle (LV): 37.2%; Right Atrium (RA): 8.5%; and Left Atrium (LA): 10.4%; specific mortalities were of 21%, 23%, 22% and 45%, respectively. The mortality injuries to two associated chambers was 37.5%, 20% being for RA + RV, 100% for RV + LV, and zero for RV + LA. The lung accounted for 33.7% of the 89 associated lesions. Mean time of surgery and hospital stay were 121 minutes and 8.2 days, respectively. About 22.5% of patients displayed 41 complications. The mortality rate was 28.4%. Lesions grade IV and V corresponded to 55% and 41% of cases, with specific mortality of 26% and 15%, respectively. All patients with grade injuries VI died.

CONCLUSION

Cardiac stab wounds were associated with lower mortality, cardiac lesions grade IV were associated with higher mortality and a shorter operative time was associated with greater severity and mortality.

The use of emergency department thoracotomy for traumatic cardiopulmonary arrest

Despite the establishment of evidence-based guidelines for the resuscitation of critically injured patients who have sustained cardiopulmonary arrest, rapid decisions regarding patient salvageability in these situations remain difficult even for experienced physicians. Regardless, survival is limited after traumatic cardiopulmonary arrest. One applicable, well-described resuscitative technique is the emergency department thoracotomy-a procedure that, when applied correctly, is effective in saving small but significant numbers of critically injured patients. By understanding the indications, technical details, and predictors of survival along with the inherent risks and costs of emergency department thoracotomy, the physician is better equipped to make rapid futile versus salvageable decisions for this most severely injured subset of patients.

A pictorial review of traumatic pericardial injuries

Background

Thoracic injuries are the third most common injuries in trauma patients with cardiac injuries amongst the most lethal. Imaging is essential in diagnosis and triage of patients with pericardial injuries, and this review aims to highlight the spectrum of imaging findings of pericardial trauma. Focussed assessment with sonography for trauma (FAST) is the preferred initial examination, being rapid and accurate. Sensitivity of FAST for pericardial fluid detection is high with reported sensitivities of 97–100%. Plain chest radiography has low sensitivity for pericardial injuries but is useful in the evaluation of associated injuries. Computed tomography (CT) is the modality of choice for stable patients and can accurately diagnose traumatic pathology of the pericardium being especially useful in identification of cardiac herniation. The spectrum of CT findings includes pericardial fluid collections, focal pericardial defects and pneumopericardium.

Methods

A selection of cases of pericardial trauma encountered at a level one trauma centre is presented. Operative findings were correlated with the FAST scan, plain radiography and computed tomography imaging.

Conclusion

The imaging findings of pericardial trauma with various imaging modalities (ultrasound, plain radiography and computed tomography) are presented in order to aid interpretation during the acute trauma setting.

Double jeopardy revisited: clinical decision making in unstable patients with, thoraco-abdominal stab wounds and, potential injuries in multiple body cavities

INTRODUCTION

In the setting of the hypovolaemic patient with a thoraco-abdominal stab wound and potential injuries in both the chest and abdomen, deciding which cavity to explore first may be difficult.Opening the incorrect body cavity can delay control of tamponade or haemorrhage and exacerbate hypothermia and fluid shifts. This situation has been described as one of double jeopardy.

METHODS

All stab victims from July 2007 to July 2009 requiring a thoracotomy and laparotomy at the same operation were identified from a database. Demographics, site and nature of injuries, admission observations and investigations as well as operative sequence were recorded. Correct sequencing was defined as first opening the cavity with most lethal injury. Incorrect sequencing was defined as opening a cavity and finding either no injury or an injury of less severity than a simultaneous injury in the unopened cavity. The primary outcome was survival or death.

RESULTS

Sixteen stab victims underwent thoracotomy and laparotomy during the same operation. All were male with an age range of 18–40 (mean/median 27). Median systolic blood pressure on presentation was 90 mm Hg. (quartile range 80–90 mm Hg). Median base excess was 6.5 (quartile range 12 to 2.2). All the deaths were the result of cardiac injuries. Incorrect sequencing occurred in four patients (25%). In this group there were four negative abdominal explorations prior to thoracotomy with two deaths. There was one death in the correct sequencing group.

CONCLUSION

Incorrect sequencing in stab victims who require both thoracotomy and laparotomy at the same sitting is associated with a high mortality. This is especially true when the abdomen is incorrectly entered first whilst the life threatening pathology is in the chest. Clinical signs may be confusing, leading to incorrect sequencing of exploration. The common causes for confusion include failure to appreciate that cardiac tamponade does not present with bleeding and difficulty in assessing peritonism in an unstable patient with multiple stab wounds. In the setting of the unstable patient with stab wounds and suspected dual cavity injuries the chest should be opened first followed by the abdomen.

Transthoracic echocardiogram is a useful tool in the hemodynamic assessment of patients with chest trauma

INTRODUCTION

The utility of transthoracic echocardiogram (TTE) in patients on the trauma service is not well defined. The aim of this study was to evaluate the frequency of abnormal echocardiographic findings that would aid in the assessment and management of cardiovascular hemodynamics in patients with chest trauma.

METHODS

A retrospective analysis of all patients who had a TTE on the trauma service at a level 1 trauma center during a 12-month period was performed.

RESULTS

There were 94 patients in the study. TTE was performed after cardiac surgery in 5 patients. One of the 5 patients with prior cardiac surgery was excluded from the study because of poor quality images, and each of the remaining 4 patients showed significant TTE abnormalities. Of the 89 patients without prior cardiac surgery, 38 (43%) had significant TTE findings although 32 (84%) of them had no known history of cardiac abnormalities. A decreased left ventricular ejection fraction (<50%) was found in 18% of all patients, and half of them were hemodynamically unstable. Significant valvular regurgitation or stenosis was found in 31 patients, pulmonary hypertension in 25 patients, left ventricular wall motion abnormalities in 12 patients and pericardial effusion in 11 patients.

CONCLUSION

Significant echocardiographic abnormalities are detected by TTE in patients with chest trauma. Such findings can be used in the hemodynamic assessment and management of unstable patients during their hospitalization and in planning long-term follow-up and management of these patients after discharge from the hospital.

Traumatic pericardial effusion: impact of diagnostic and surgical approaches

INTRODUCTION

In trauma patients with chest injuries, traumatic pericardial effusion is an important scenario to consider because of its close linkage to cardiac injury. Even with advances in imaging, diagnosis remains a challenge and use of which surgical approach is controversial. This study reviews the treatment algorithm, surgical outcomes, and predictors of mortality for traumatic pericardial effusion.

PATIENTS AND METHODS

Information on demographics, mechanisms of trauma, injury scores, diagnostic tools, surgical procedures, associated injuries, and hospital events were collected retrospectively from a tertiary trauma center.

RESULTS

Between June 2003 and December 2009, 31 patients (23 males and 8 females) with a median age of 31 (range 16-77), who had undergone surgical drainage of pericardial effusion were enrolled in the study. Blunt trauma accounted for 27 (87.1%) insults, and penetrating injury accounted for 4 (12.9%). Patients were diagnosed by Focused Assessment with Sonography for Trauma (FAST) (8 patients), computerized tomography (7 patients), echocardiography (9 patients), and incidentally during surgery (7 patients). Notably, sixteen (51.7%) patients required surgical repair for traumatic cardiac ruptures, including 6 (19.6%) with pericardial defects who presented initially with hemothorax. The surgical approaches were subxiphoid in 8 patients (25.8%), thoracotomy in 7 (22.6%), and sternotomy in 19 (61.2%), including 3 conversions from thoracotomy. The survival to discharge rate was 77.4% (24/31). Concomitant cardiac repair, associated pericardial defects, and initial surgical approach did not affect survival, but the need for massive transfusion, cardiopulmonary cerebral resuscitation (CPCR), trauma score, and incidental discovery at surgery all had a significant impact on the outcome.

CONCLUSIONS

Precise diagnoses of traumatic pericardial effusions are still challenging and easily omitted even with FAST, repeat cardiac echo and CT. The number of patients with traumatic pericardial effusion requiring surgical repair is high. Standardized therapeutic protocol, different surgical approaches have not impact on survival. Correct identification, prompt drainage, and preparedness for concomitant cardiac repair seem to be the key to better outcomes.

Challenges in the diagnosis of blunt cardiac injuries

INTRODUCTION

Blunt thoracic injuries (BTIs) are directly responsible for 20-25% of all deaths, worldwide. Involvement of heart in BTIs is largely underestimated and ignored, but reasonable estimate would be around 15%. This study was planned to emphasize on clinical-presentation and diagnosis of blunt cardiac injuries (BCIs).

RESULTS

Clinical presentation of BCIs, varied from mild chest discomfort to haemodynamic shock secondary to rapid exsanguinations. Non-specific presentation with associated injuries diverts physician's attention and delayed appearance of clinical features makes diagnosis further difficult. Cardiac markers and ECG are not specific, but high sensitivity of 100% could be reached using combination of elevated cardiactroponin levels and alterations in ECG. Transoesophageal or transthoracic echocardiography, angiography, intravascular ultrasound and nuclear scan have proven to detect cardiac injuries in BTIs, but lack specificity.

CONCLUSION

Patients with suspicious-ECG finding need cardiac-monitoring for at least 24 hours. Haemodynamically stable young (<55 years) subjects, without underlying cardiac diseases and with normal-ECG and cardiac marker, could be discharged safely.

Penetrating cardiac injury: overcoming the limits set by Nature

Repair of cardiac wounds was considered impossible little over 100 years ago. Despite progress, penetrating cardiac injury remains a highly lethal form of trauma today. Cardiac tamponade and exsanguination are the greatest immediate and life-threatening risks. Clinical presentation is extremely variable and diagnosis may be highly deceptive. Unlike other forms of trauma, resuscitation is of limited value and urgent operative intervention is the only meaningful treatment. Refinements in cardiothoracic surgery and the simultaneous evolution of trauma care systems have both contributed to saving lives. However, mortality rates for this condition have changed little in the last century, due largely to the rising proportion of more lethal injuries caused by gunshot wounds.

Current Role of Emergency US in Patients with Major Trauma

In patients with major trauma, focused abdominal ultrasonography (US) often is the initial imaging examination. US is readily available, requires minimal preparation time, and may be performed with mobile equipment that allows greater flexibility in patient positioning than is possible with other modalities. It also is effective in depicting abnormally large intraperitoneal collections of free fluid, which are indirect evidence of a solid organ injury that requires immediate surgery. However, because US has poor sensitivity for the detection of most solid organ injuries, an initial survey with US often is followed by a more thorough examination with multidetector computed tomography (CT). The initial US examination is generally performed with a FAST (focused assessment with sonography in trauma) protocol. Speed is important because if intraabdominal bleeding is present, the probability of death increases by about 1% for every 3 minutes that elapses before intervention. Typical sites of fluid accumulation in the presence of a solid organ injury are the Morison pouch (liver laceration), the pouch of Douglas (intraperitoneal rupture of the urinary bladder), and the splenorenal fossa (splenic and renal injuries). FAST may be used also to exclude injuries to the heart and pericardium but not those to the bowel, mesentery, and urinary bladder, a purpose for which multidetector CT is better suited. If there is time after the initial FAST survey, the US examination may be extended to extra-abdominal regions to rule out pneumothorax or to guide endotracheal intubation, vascular puncture, or other interventional procedures.

The accuracy of thoracic ultrasound for detection of pneumothorax is not sustained over time: a preliminary study

BACKGROUND

Ultrasound has proven to be very accurate in the diagnosis of pneumothorax in the trauma suite. It is unknown whether this accuracy is maintained over time in patients with a thoracostomy (TT) in place.

METHODS

Hospitalized patients with a TT placed to treat a traumatic pneumothorax underwent serial daily bedside surgeon-performed ultrasound by 1 of 2 experienced surgeon sonographers who were unaware of concomitant X-ray findings. Results were compared with daily chest X-ray films. Data collected included size and day of placement of the chest tube, as well as the results of the serial ultrasounds and the comparative X-ray films.

RESULTS

Fourteen patients (78% men, mean age 33 years) sustained traumatic pneumothorax. The causes included stab wound (9), gunshot wound (3), and rib fracture (2). They underwent 126 (median 7) ultrasound evaluations and were followed between 4 and 26 (median 7) days after injury. Of these exams, 95 had a concomitant chest X-ray film within 1 hour of the ultrasound, thus 190 hemithoraces could be analyzed. Eighty-two ultrasounds were performed for hemithoraces that had no injury or TT in place and all 82 revealed normal pleural sliding. No pneumothoraces were noted on concomitant chest X-ray films (100% accuracy). One hundred eight ultrasounds were performed for hemithoraces that had a TT in place. For the first 24 hours, accuracy remained 100%. After 24 hours, however, sensitivity of ultrasound diagnosis of pneumothorax fell to 55%, specificity fell to 70%, positive predictive value to 43%, and negative predictive value to 79%. This led to an overall accuracy rate for ultrasound examination after 24 hours of 65%.

CONCLUSIONS

Ultrasound evaluation for pneumothorax is very accurate for the first 24 hours after insertion of a TT, but the accuracy, especially the positive predictive value, is not sustained over time, possibly as a result of the formation of intrapleural adhesions.

Definitive management of acute cardiac tamponade secondary to blunt trauma

Blunt cardiac injuries are a leading cause of fatalities following motor-vehicle accidents. Injury to the heart is involved in 20% of road traffic deaths. Structural cardiac injuries (i.e. chamber rupture or perforation) carry a high mortality rate and patients rarely survive long enough to reach hospital. Chamber rupture is present at autopsy in 36-65% of death from blunt cardiac trauma, whereas in clinical series it is present in 0.3-0.9% of cases and is an uncommon clinical finding. Patients with large ruptures or perforations usually die at the scene or in transit--the rupture of a cardiac cavity, coronary artery or intrapericardial portion of a major vein or artery is usually instantly fatal because of acute tamponade. The small, rare, remaining group of patients who survive to hospital presentation usually have tears in a cavity under low pressure and prompt diagnosis and surgery can now lead to a survival rate of 70-80% in experienced trauma centres. As regional trauma systems evolve, patients with severe, but potentially survivable cardiac injury are surviving to ED. Two distinct syndromes are apparent--haemorrhagic shock and cardiac tamponade. Any patient with severe chest trauma, hypotension disproportionate to estimated loss of blood or with an inadequate response to fluid administration should be suspected of having a cardiac cause of shock. For patients with severe hypotension or in extremis, the treatment of choice is resuscitative thoracotomy with pericardotomy. Closed chest cardiopulmonary resuscitation is ineffective in these circumstances. Blunt traumatic cardiac injury presenting with shock is associated with a poor prognosis. The majority of survivors of blunt or penetrating cardiac injury present to the ED/trauma centre with vital signs. The main pathophysiologic determinant for most survivors is acute pericardial tamponade. The presence of normal clinical signs or normal ECG studies does not exclude tamponade. In recent years the widespread availability and use of ultrasound for the initial assessment of severely injured patients has facilitated the early diagnosis of cardiac tamponade and associated cardiac injuries. Two cases of survival from blunt traumatic cardiac trauma are described in the present paper to demonstrate survivability in the context of rapid assessment and intervention.